AW-25 — Management Review and External Reporting Calendar

1. Purpose and scope

Purpose. To ensure that IoL's leadership reviews the whole management system at least annually on the evidence ISO 9.3 requires, decides what will change and what resources it needs, and records those decisions where they can be tracked; and that every recurring obligation to an external body is known, owned, dated, sourced and evidenced in one calendar.

Scope statement. This procedure manages the departmental management review from the collection of inputs to the tracking of outputs, and the external reporting calendar from the identification of an obligation to the evidencing of its fulfilment.

Applies to. The annual management review and any interim review the Senior Director, IoL, calls; every recurring obligation to a regulator, accreditor, ministry, certification body or Dubai Health function for which IoL prepares content, whether IoL or MBRU submits it.

Does not apply to. MBRU's institutional management review, to which this review is an input; the content of any submission, which belongs to the producing procedure (WF-26, WF-05, WF-21); one-off requests, which follow AW-04.

2. Trigger, boundary and interfaces

3. Roles and accountability

Process owner. IoL Quality Lead or equivalent [IoL to confirm], with authority to place any item on the management review agenda.

[CONTROL] Segregation. Input owners supply their own measures; the process owner does not restate them. A return is prepared by its row owner and approved by the Senior Director, IoL, before submission. Decisions are taken by the committee, not by the process owner who compiled the pack.

4. Procedure

Part A. Management review

1. Schedule. The review is a standing item on the AW-01 calendar, at least annually and timed so that its outputs feed the AW-02 planning call, chaired by the Senior Director, IoL, and minuted under AW-01. [CONTROL] A year without a minuted management review is a major non-conformity under AW-24.

2. Call for inputs. Twenty working days before the review the process owner requests each input from its owner in a standard template. The required inputs are:

   Input (ISO 9.3.2)	Source
   Status of actions from the previous review	AW-01 action register
   Changes in external and internal issues relevant to the system	Senior Director, IoL; AW-03 external documents register; this calendar
   Performance and effectiveness: every procedure's section 7 or 13 measures against target	Each AW and WF owner
   Customer and stakeholder satisfaction and feedback	WF-06, WF-14, AW-20, AW-18, AW-22
   Extent to which objectives were met	AW-02 register of objectives
   Process performance and conformity of services	AW-24 audit results; service standards attainment
   Non-conformities and corrective actions	AW-24 CAPA register
   Monitoring and measurement results	AW-25 calendar fulfilment; WF-26 submission outcome
   Audit results, internal and external	AW-24; WF-05; ISO certification body
   Performance of external providers	AW-10, AW-11, AW-23 supplier and partner performance
   Adequacy of resources	AW-02 outturn; AW-07 vacancies; AW-13 and AW-14 condition
   Effectiveness of actions to address risks and opportunities	AW-06 register and continuity test results
   Opportunities for improvement	Any owner; AW-24 observations

   [CONTROL] An input reported as "no change" is accepted only with the owner's signature and the date of the data it rests on.

3. Compile and circulate the pack. The process owner flags every measure below target, overdue action and risk above tolerance, and circulates the pack through the AW-01 paper deadline. Missing inputs are listed by name on the first page.

4. Conduct the review. The committee considers each input, and for each records one of: no action, action with owner and date, or referral to AW-02 for resource. The required outputs are minuted explicitly: decisions on opportunities for improvement; decisions on changes to the management system, including procedures to be revised through AW-03; and resource needs, with the AW-02 route. [CONTROL] The minutes name each of the three ISO 9.3.3 output categories, even where the decision is that nothing changes.

5. Track outputs. Actions enter the AW-01 action register and are reported at each subsequent committee meeting. Resource needs enter the AW-02 plan. Changes to procedures open AW-03 change requests. Their status is the first input to the next review.

6. Report upward. The Senior Director, IoL, provides the minuted outputs to MBRU's institutional management review or quality function in the form MBRU requires [IoL to confirm].

Part B. External reporting calendar

7. Build and maintain the calendar. A controlled register holds every recurring external obligation with the body, obligation, frequency and due date, row owner, producing procedure, source document (held under AW-03 as an external document of origin), approver, submitting function and evidence location. Initial rows, all dates [IoL to confirm]:

   Body	Obligation	Due	Owner	Producing procedure
   MoHESR (CAA)	Institutional and programme accreditation reporting and licensure conditions	______	Programme lead	WF-05
   MoHESR (CHEDS)	OBEF and CHEDS annual data submission	Window per WF-26	Pilot Lead	WF-26 (cross-reference only)
   MoHESR	Non-OBEF returns and surveys [IoL to list]	______	______	AW-04 or producing procedure
   DHA or applicable CME accreditor	CME provider accreditation reporting, activity returns [where applicable]	______	CPD lead	WF-21
   ISO certification body	Surveillance and recertification audit, evidence of management review and internal audit	______	Quality Lead	AW-24, AW-25
   MBRU planning and finance	Planning and budget submissions, year-end	Per AW-02	Operations Manager	AW-02
   Dubai Health	Any departmental return required of MBRU academic units [IoL to confirm]	______	______	______
   Partners under agreement	Contractual reporting to funders and partners	Per agreement	Partnership lead	WF-17, WF-24, AW-23

   [CONTROL] A row without an owner and a source document is incomplete and is flagged at every monthly check.

8. Issue reminders. The process owner reviews the calendar monthly and issues reminders to row owners at 60, 30 and 10 working days before each due date [IoL to confirm intervals].

9. Prepare and approve the return. The row owner prepares the return through the producing procedure and the Senior Director, IoL, approves it. [CONTROL] No return leaves IoL without the approval recorded against the calendar row, and none is submitted in MBRU's name except by the MBRU function authorised to do so.

10. Evidence fulfilment. The row owner records the submission date, the acknowledgement, the evidence location under AW-04 and any conditions or follow-up received. Late or deferred returns are recorded with the reason and reported at the next AW-01 meeting.

11. Review the calendar annually. At the management review the calendar is confirmed complete, obligations added or removed, and the year's fulfilment reported.

Exception routes. A new obligation discovered mid-year is entered within 5 working days and the Senior Director, IoL, decides whether to meet the date or request a deferral. An interim management review may be called for a major external change, serious incident or major non-conformity and follows the same inputs and outputs in reduced scope.

5. Service standards

6. Records, retention and controls

Key controls. (1) Management review held and minuted at least annually. (2) Every ISO 9.3.2 input supplied by its owner with a data date. (3) Every ISO 9.3.3 output category minuted. (4) Outputs tracked through AW-01, AW-02 and AW-03. (5) Every calendar row has an owner, a source document and an evidence location. (6) Every return approved before submission and submitted only by the authorised function. (7) Fulfilment evidenced within the standard.

OBEF touchpoint. None directly. The OBEF and CHEDS row records the window, owner and evidence location; WF-26 owns the content and the capture rules.

7. Performance measures

8. Change control